Download Instructor Resource Manual, Module 6 – Relating

Instructor Resource Manual
Module 6 – Relating
Table of Contents
Lecture content outline
Post-lecture knowledge assessment items
Answer key and rationale for knowledge assessment items
Observation assessment form and scoring rubric
Sample Case
Sample case group debrief questions and instructor guide
Sample case role-play activity
Reflective writing assignment and instructor guide
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Content Outline for Lecture
I.
Introduction to COMFORT
a. COMFORT is an acronym that stands for 7 basic principles designed to be taught in
early palliative care communication, care provided for individuals with a lifethreatening or serious illness
b. The curriculum is based on empirical research in hospice and palliative care,
including observations of interprofessional teams, team meetings, team member
collaboration, and interviews with team members across a range of healthcare
professions.
c. This lecture will provide an overview of module 6 – Relating, and more specifically
team meetings. This module is an introduction to advanced-level communication
skills.
II.
Objectives
a. The objectives of this session are to learn about the multiple goals people have when
they communicate and to consider the ways that we can adapt to patient and family
perspectives.
b. Relating to patients and families is centered on engaging in critical turning points to
advance patient /family understanding.
c. The focus is on relational communication and sharing meaning in order to facilitate
instrumental goals (providing physical care).
III.
Adapting to Patient and Family
a. This communication skill is aimed at two important turning points:
i. patient/family acceptance of a diagnosis/prognosis
ii. patient/family understanding of new information within the illness journey
b. Bad news is defined by the patient/family. What you consider bad news may not be
bad news to the patient/family.
c. Talking and communicating in a way that is radically adaptive assumes that you
cannot know the reaction or perspective of the patient/family without first receiving
it. It requires putting the “other person” first.
i. Diversified approaches and responses to a topic can be referred to as
diffusion of topics.
IV.
Understanding the Quest (Frank, 1995)
a. To accept news or change is to acknowledge that it is real and assent to that
information in planning, behavior, and communication.
b. To find something useful from the experience is called a quest narrative.
c. Patient/family acceptability requires them to acknowledge significant changes
following an illness
d. Acceptability and discovery is gained from an event or critical turning point and
brings a sense of identity related to the illness.
e. To help patient/family, focus on the turning points in the illness journey and what
they mean.
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V.
Engaging Uncertainty
a. As patient/family experience uncertainty over the meaning of disease progression,
symptom, and impact of treatment, clinical communication involves helping them
process uncertainty.
b. This may be very different for patient and family members.
c. Quality of life and what they understand as “normal” are threatened by the unknown
future.
VI.
Problematic Integration (Babrow, 1992)
a. Changing probabilities about the disease and changing values about acceptable
quality of life create uncertainty for the patient and family.
b. Especially in a team-based health care system, there can be variances of
communication among team members with patient/family as well as variance in
communication messages that contribute to feelings of uncertainty.
c. There are two concepts for how we process uncertainty.
i. Probability
ii. Evaluation
d. Common questions from patients as they explore their uncertainty include:
i. Why is this happening to me? Why is this happening now?
ii. How long do I have to live?
iii. Do you think I am dying?
VII.
Uncertainty arises when….
a. When probability and evaluation do not compliment one another, then
communication and decision-making become difficult.
b. Here are four ways that patient/family communicate when there is uncertainty:
i. Divergence – patient doesn’t express understanding of impact to routine life
ii. Ambiguity – patient identity is changing and difficult
iii. Ambivalence – patient expresses understanding of future but makes choices
that deny or conflict with reality
iv. Impossibility - patient maintains hope for better outcome despite certainty
that the outcome will not happen
VIII.
Rationalizations in decision-making
a. Recognizing statements revealing problematic integration invites clinicians to
recognize indicators of low acceptability from patients and families.
b. Here are some examples from patients.
IX.
Speech Acts (Austin, 1962; Searle, 1969)
a. Identifying acceptability also involves considering what is actually being said (and
done) when words are spoken.
b. When people convey information, often times they communicate much more than
their words encode.
c. Words are often received in a way that is NOT intended to be received.
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OPTIONAL: Ask the audience if they have ever miscommunicated with someone and it
turned out to be that they misinterpreted the message. For additional demonstration of
this, find a cartoon strip that shows the inner thoughts of a character and how they may
differ from the meaning of the interaction being depicted. Cartoon strips establish
effective humor by playing on this connection or disconnection between words and
meanings by placing them in context.
X.
Words exert action
a. Context determines what words mean.
b. The act of saying something is the verbal word.
c. What a person is doing in saying something is the performance, or contextual
function of the word. For example, “How is your pain?”
d. A speech act is the action that takes place by saying something. For example, when
you say ‘I quit’ you are actually quitting. There is a secondary effect on the listener
that cannot be predicted.
e. Giving bad news is a good example of how words have action in a specific context.
XI.
The Effects of Words
a. Here is an example of the three actions of words.
b. Typically, following a terminal diagnosis, the focus of discussion is on curative
treatment and decision-making.
c. Rather than discussing the meaning of the prognosis, the prognosis itself is not
discussed because the language is threatening --- the thing itself is discussed, remade,
enlarged.
d. As a clinician, your role is to engage in these constrained topics to aid patient/family
acceptability.
XII.
What someone is doing in saying something
a. A direct speech act presents one action, but in actuality is acting on two or possibly
more matters of action with one statement.
b. A direct speech act unpacks the content of what someone does in saying something.
c. Indirect speech acts present possible actions exerted through spoken words.
d. Here are some examples of how a statement can have two meanings.
OPTIONAL: Have the audience recall a time when someone said something special to
them. Ask them to write down that statement, who said it, where they were, and what it
meant to them. Then ask them to reflect on the statement. The statement likely has little
or different meaning without understanding the context and the meaning behind the
statement has special meaning to them, given the context in which it was said or the
relational history between the two speakers.
XIII.
Multiple Goals at Play
a. Task level communication is the content of the message and includes what the
message intends to do. For example, task communication involves teaching and
educating patient/family members.
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b. While the content level of a message is conveyed by the words themselves (task
communication), the relational level generally is manifested by nonverbal
communication. Relational level demonstrates how we relate to patient/family
through the nonverbal messages we convey.
c. Because clinicians pursue multiple goals (e.g., you are trying to check blood pressure
and get a pain rating at the same time), problems can be common in interaction.
d. As we interact with patient/family, new goals emerge from indirect speech acts.
Relating is a necessary communication strategy as goals change throughout the
interaction and as you recognize indirect speech acts and interpret their meaning.
XIV. In Practice…
a. New goals emerge as each speaker makes certain conversational moves in the
interaction.
b. Turning points for a patient or family sometimes are identified in the way that they
are communicated.
c. Adaptive communication can be used when a patient becomes agitated or cannot
reach acceptability.
d. Diffusion of topics can be used if patient/family stray from topic or avoid speaking
about topic. Diffusion of topics involves repeating and inserting the topic continually
throughout the conversation. Suspend the need to achieve your goals in work and
focusing on relating in order to achieve patient/family acceptability.
XV.
Team-based Relating
a. Rather than focusing on prescribed checklist of information to provide or instructions
to give, we advocate that you are adaptive. While each team member has specific care
tasks to accomplish, the relational level of communication should be emphasized.
Allow patient and family to guide the order of your checklist.
b. Multiple goals need to be recognized. Listen to what the patient/family have to say
and the questions they ask. Think about the meaning behind the question – the
meaning to them and their family.
c. Don’t forget to use other members of the team! Team members are there for more
than simply a referral for a specialize service or care need. Use team members to help
relate to patient and family. There may be someone on the team that relates to the
patient and family because of similarities (e.g., grew up in similar location, share
family history of occupation, similar age/race/ethnicity, etc.).
References
Austin, J. L. (1962). How to do things with words. Oxford: Oxford University Press.
Babrow, A. S. (1992). Communication and problematic integration: Understanding diverging
probability and value, ambivalence, and impossibility. Communication Theory, 2, 95130.
Frank, A. (1995). The Wounded Storyteller. Chicago: University of Chicago Press.
Searle, J. (1969). Speech acts: An essay in the philosophy of language. Cambridge: Cambridge
University Press.
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Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and
palliative nursing. New York: Oxford Press.
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Post-Lecture Knowledge Assessment Items
1. What is involved in adapting to patient and family?
a) Determining what the patient considers bad news
b) Diffusing topics by discussing sports
c) Recognizing that patient/family define what is bad news
d) Engaging in radically adaptive care interventions
2. Patient/family members attempt to manage and process their uncertainty by
a) Considering probabilities and evaluating outcomes
b) Considering the background of their healthcare team
c) Considering where they live and where the hospital is located
d) Considering what college their physician attended
3. A woman suffering from stage IV cancer with metastasis to the liver, bone, and lymph nodes
explained to her social worker: “After these treatments, I will be right back at work and
returning to my role as Head Girl Scout Leader for my daughter’s troop.”
Her statement is an example of:
a) Ambiguity
b) Divergence
c) Ambivalence
d) Impossibility
4. At the airport, travel partner Jo asks travel partner Bill, “Are you sure this is the right gate for
us?” as they await an outbound flight. What indirect speech act could Jo be implying?
a) Jo is admitting she doesn’t know what time the plane leaves.
b) That Jo and Bill are at the wrong gate.
c) That Jo doesn’t trust Bill’s navigation.
d) Either A or C.
5. Multiple goals are at play during interactions and are produced by:
a) Task and Relational level of messages
b) Adaptive communication strategies
c) The discovery of illness
d) Problematic Integration
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ANSWER KEY - Post-Lecture Knowledge Assessment Items
1. Answer: C
Rationale: Bad news is defined by the patient/family. What you consider bad news may not
be bad news to the patient/family. To accept news or change is to acknowledge that it is real
and assent to that information in planning, behavior, and communication.
2. Answer: A
Rationale: Uncertainty results from the problematic integration of the way a person feels
about something (positive or negative emotional value) and their perceived probability that
something will occur.
3. Answer: B
Rationale: Patients and families attempt to manage uncertainty when what they want (cure) is
not likely to happen, and they perceive a declining status. Divergence is the discrepancy
between what we want (evaluative) and what is likely (probabilistic).
4. Answer: D
Rationale: There are indirect meanings at work in Jo’s question. When a speaker says
something, the force or action of their speech carries more meaning. In this case, Jo’s indirect
speech act could be implying that the gate is wrong or that she doesn’t trust Bill’s navigation.
Indirect speech acts are the implied meaning behind the words themselves.
5. Answer: A
Rationale: Every person accomplishes, or attempts to accomplish multiple goals in
interactions. Sometimes these goals are emergent, and sometimes people enter in interaction
knowing very clearly what they need/want to achieve. The instrumental goal is the basic
purpose of the interaction, and the relational level is how individuals present themselves and
the impact of the goal pursuit on their relationship with the person.
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The COMFORT Communication Assessment Scale
Module 6 – Relating
Student:_______________________
Element
Unacceptable
(1)
Patient/family
perspective on
illness is not
explored
Poor
(2)
Patient/family
perspective on
illness is
mentioned but
not engaged
Acceptable
(3)
Patient/family
perspective on illness is
included often in
encounter
Good
(4)
Patient/family perspective
on illness is explored in
conversation and developed
by patient/family
Communication is
guided by
patient/family
acceptability:
Diffusion of
Topics
Neglects to adapt to
patient/family
acceptability in light
of clinician agenda
Acknowledges
acceptability
level but neglects
to converge with
this level
Responsive to
acceptability level of
patient/family within
the interaction
Inquires about acceptability
level and integrates
knowledge into current
meeting and plan of care
Acknowledgement
of significant
changes in health
status
No inquiry into
health status
Changes in health
status noted once
during interaction
Changes in health
status are discussed by
clinicians
Changes in health status are
explored with scenarios,
stories, reflections, and
incorporate all members
present
Explore turning
point in the illness
trajectory and its
impact on the
quality of life
domains
No inquiry into
critical turning point
in health
Clinician
prioritizes task
(conveying
information) over
relational
(conveying
support/empathy)
content
Clinician recognizes
patient/family concerns,
and attempts to relate to
patient/family
Clinician is highly
responsive to patient and
family concerns and
discusses quality of life
domains as patient/family
are able
New life and care
options are
explored
No inclusion of new
opportunities in
illness
Clinician includes
task goals that
present new
opportunities
Clinician incorporates
task and relational
content in discussing
new opportunities
Uncertainty is
included as an
important aspect
of illness
trajectory
Provides no
opportunity for
patient/family
feelings and
descriptions of
uncertainty
Recognizes
patient/family
feelings and
descriptions of
uncertainty
Demonstrates empathy
for patient/family
feelings and
descriptions of
uncertainty
Clinician is highly
responsive to patient/family
goals (task and relational)
in discussing quality of life
domains
Creates opportunities for
patient/family to explore
and understand their own
feelings and descriptions of
uncertainty
Recognition of
multiple and
competing goals
expressed by
patient/family
Remains biomedical
in focus
Minimal
acknowledgement
of patient/family
identity (e.g..
occupation,
name, hometown)
Inquires about
patient/family identity
factors in illness.
Adaptive response
to the
patient/family
perspective on
illness
Creates opportunities for
patient/family to articulate
their own personal needs
and goals
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Comments to be filled out by students following viewing of videotaped encounter:
1. Regarding (relating) communication skills, what did you think went well?
2. Regarding communication with this patient/family member (role play), what, if anything, would you do
differently?
3. What are the barriers and pathways you see in communicating with the patient/family? The team?
4. Any other observations or comments about this particular patient/family encounter?
NOTE: Feel free to refer to R-Relating and O-Openings of COMFORT when reflecting on which tasks you accomplished, as well
as the way in which you accomplished them.
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Sample Case
Sue Lanz, 33, and her family believed that she was enduring either the strange after effects of a
laparoscopy surgery or some complication from her diabetic pump. A mass on her rectus
abdominal muscle had been steadily growing since an oophorectomy three months previous. At
this same time, Sue had been offered a promotion as an Associate Pastor to a church across the
country. Feeling fine, though losing weight, Sue and her husband Phil moved. In her second
week in a new place, Sue made a doctor’s appointment concerning her growing mass. She was
referred to an infectious disease specialist who pursued it as infection. After two weeks of an
antibiotic therapy, the physician ordered an x-ray, revealing profuse bilateral tumor activity in
her lungs. An open biopsy was ordered. Her tumor, as well as several lymph nodes, was read by
pathology as poorly differentiated adenocarcinoma.
Sue and Phil met with a local oncologist for care. After finding his communication with them
unclear and void of empathy, they pursued treatment at a comprehensive cancer center. Once
arriving there, the diagnosis became graver, as further tests revealed advanced metastatic spread.
Still though, Sue and Phil were offered treatment. The cancer center coordinated the
chemotherapeutic components of the care at a small local cancer clinic near their home, while
they commuted across the country for specialized radiation treatments at the comprehensive
cancer center.
Over the next few months, Sue endured profound side effects from her treatments. Her quality of
life was markedly diminished. Despite the grim outlook of her diagnosis and diffuse spread of
disease, Sue and her family waded further into a dizzying carousel of clinicians, side-effects,
appointments, and travel.
Sue continues to remain in place as the Associate Pastor in her new job, despite the fact that she
is heavily medicated, in pain, and weak. Her brother has moved in and travels to and from work
each day with Sue to oversee her physical well-being and facilitate her work efforts.
Phil’s Profile: Finishing doctoral work at a nearby university, Phil tries to juggle his life
outside of his wife’s illness with his professional hopes. He continues to pursue his degree and is
gone from the home and Sue half of the week to accommodate his commute. As a result, Phil
leaves the door open for his brother-in-law to move in and become Sue’s constant companion
and caretaker.
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Sample Case Group Debrief Questions
1.
When encountering Sue in the clinical setting, how might you explore issues of
uncertainty and illness with her?
Instructor Guide: This patient is focused heavily on her work. There is no clear
indication that Sue has discussed prognosis or sought out resources to deal with an
incurable cancer. The team might not know Sue’s understanding of her disease or her
level of uncertainty about this grave diagnosis. Example:
“Sue, can you describe what you are thinking about your diagnosis?”
2.
What might the team want to find out about concerning Sue, her brother, and her
husband?
Instructor Guide: Learning about the family’s understanding of the Sue’s illness is
important in informing a team about how the family is coping. Also, each person’s
goals might be aligning, or perhaps diverging, based the level of disease
understanding.
3.
How could an effective conversation about Sue’s illness trajectory inform her
husband’s goals? Her brother’s? Sue’s?
Instructor Guide: Each member of this family appears to be on a different path,
though they all are living in the same life---Sue’s. Sharing in and being exposed to
information about Sue’s illness will inform all of them, allowing a better opportunity
to prioritize.
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Role Play Activity
Objectives:
1.
2.
3.
4.
Practice identifying patient/family goals.
Identify specific opportunities to explore patient/family goals and their differentiation.
Engage in role-play activities informed by patient/family uncertainty.
Extend the relating module to actual communication application.
How to Proceed-Introduction & Discussion: (20 minutes)



Review objectives for group activity and facilitate introductions of group members to one
another.
Ask group participants to read case.
Facilitate discussion of speech acts and relating.
How to Proceed-Role Play: (20 minutes)
Roles: There are several roles to be played in this case; remaining participants can observe
Facilitator: Keep time (20 minutes MAX for this part of group activity, as divided below):
 5 minutes for role players to read roles and arrange seating for conversation
 10 minutes for role play
 5 minutes for de-brief and discussion.
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Family Meeting Role Play
Situation: This morning, Sue, meets with her care team. She has been briefly hospitalized for a
blood transfusion and skin biopsies that tested positive for cancer on the dermis directly
overlaying a tumor site.
Sue no longer walks without the support of her brother or husband, showers in a seated position,
and is constantly accompanied by others regardless of the context. She has recently fallen and
has a sprained right ankle, but has little sensation; this injury has caused profuse bruising and
swelling in the area. Her chart indicates that Sue cannot lift herself up and down off of the toilet.
Additionally, there are descriptions of her advanced cancer spread with metastases to the eye,
liver, spine, shoulders, hips, femurs, and lungs.
In asking questions about pain, Sue describes frequent intractable pain. She is eager to move
forward on planning regular therapy and also describes upcoming chemotherapy and radiation
treatments.
Upon entering the hospital room, Sue, is packing up for their drive home. Sue has made the
request to see a physical therapist as she would like to begin on a strengthening and balancing
program.
Just then, Sue’s husband, Phil, enters the room to carry down more luggage to their car. He
walks in as the consulting PT asks about a walker for Sue. Phil scoffs and says “over my dead
body,” quickly rushing about the room to gather more of their things. Suddenly, without
warning, he drops the load in his arms on the floor and yells to the clinicians present, “Just get
the hell out of here!”
Present: Sue (patient), Phil (Sue’s husband), Dr. Bell (PT), Dr. Jill Lundquist (oncologist), and
Cheryl Ross (social worker)
Sue, received a diagnosis of cancer 6 months ago. She still maintains a thriving social work
practice and has no children. Her sister is the primary caregiver for her.
Phil, is Sue’s husband. He is a graduate student in a nearby PhD program and continues with
his studies and teaching during Sue’s illness. They have been married for six years.
Dr. Steve Bell, has just completed her Doctorate in Physical Therapy and is working on an
oncology floor.
Dr. Jill Lundquist, is Sue’s oncologist of 9 months. She has mentioned hospice in one
previous conversation but wants Sue to seriously consider other care options that would be
less toxic than chemotherapy and radiation.
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Cheryl Ross, social worker, talked independently with Sue and Sue’s sister the previous day.
She quickly picked up on cues from the sister that the family’s current management plan for
Sue was stressed to the limit.
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Reflective Writing Activity
Elena Marquez is a 12-year old girl with end-stage sarcoma who has been seen by the pediatric
palliative care service in the Children’s Hospital for the last three years. Elena’s cancer is
metastatic with protracted bone pain. Elena’s mother, her only parent, has two younger children
and also cares for her own mother with Alzheimer’s disease. Both the nurse and social worker
have observed that while Elena is generally open in describing her pain or other symptoms, when
her mother is present she does not complain and minimizes any symptoms. She tells the nurse
later, after her mother has gone, that it is easier to bear the pain than to see her mother’s distress,
which Elena believes increases when she reports symptoms or takes medications. Seeing the
clinician’s concerns Elena becomes very withdrawn, saying “Do not talk to my mother about my
pain and upset her. Actually it’s much better now.”
Questions:
1.
What could each team member do to contribute to a solution for Elena?
2.
What indirect speech acts are associated with Elena’s request? What multiple
goals do you interpret?
3.
How is Elena managing her uncertainty?
Instructor Debrief
Physical pain management is most effectively practiced when clinicians employ the best
evidence and skills to support patients and families. Elena’s reluctance to discuss pain
management is challenging and has the potential to become fully debilitating not only for Elena,
but also for her mother. Responding to patient and family needs involves recognizing that
statements have multiple meanings and goals. Practicing clinical communication includes an
awareness of these multiple goals to better support patient care. The clinician can move beyond
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what is said to interpret multiple meanings between patients and families, often dependent upon
relational history, and explore and address more truthful and complex statements. For Elena, the
goal driving most of her communication is the protection of her mother and siblings.
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